Estimate the burden of malnutrition among children with cerebral palsy in Sub-Saharan Africa: a systematic review with meta-analysis

Malnutrition is more prevalent among children with cerebral palsy and a major factor for child morbidity and mortality in children with different co-morbidity, especially in Sub-Saharan Africa: The main aim of this systematic review and meta-analysis was to estimate the burden of malnutrition among children with cerebral palsy in Sub-Saharan Africa. We searched PubMed, Web of Science, Google Scholar, Research Gate, and institutional repositories for papers that reported the proportion of malnutrition among children with cerebral palsy that were published between December 2010 and September 2023. Data were retrieved using the standardized JBI data extraction checklist through Microsoft Excel, and then exported to STATA 17 for further analysis. DerSimonian and Laird’s estimator was used to calculate the pooled effect size in the random-effects model. Statistics such as the Cochran Q test and I2 test were employed to measure heterogeneity. Egger's test and the funnel plot were used to look for publication bias. This systematic review and meta-analysis used 16 studies from Sub-Saharan Africa to estimate the proportion of malnutrition among 2,120 children with cerebral palsy. The pooled proportion of malnutrition among children with cerebral palsy in Sub-Saharan Africa by using random-effects model analysis was found to be 59.7% (95% CI; 49.8–69.6). The proportion of malnutrition was also estimated by sample sizes categorized as ≤ 120 and > 120, and the proportion of malnutrition was found to be 54.0 (95% CI: 44.7–63.3) and 64.5 (95% CI: 50.5–78.5). Moreover, the proportion of malnutrition was estimated by accounting for the difference in the year of publication. In this regard, the study classified before ≤ 2017 and > 2017, and the proportion of malnutrition was found to be 53.7 (95% CI: 38.0–69.3) and 62.5 (95% CI: 49.7–75.3) in Sub-Saharan Africa respectively. Malnutrition among children with cerebral in Sub-Saharan Africa was found to be very high. Hence, enhancing and developing strategic guidelines for malnutrition screening, prevention, and nutritional support are crucial among children with cerebral palsy. Furthermore, systematic review, randomized control trials, and qualitative studies are recommended to understand the burden more among children with cerebral palsy in the continent.


Review question
The review question of this systematic review and meta-analysis is: What is the burden of malnutrition among children with cerebral palsy in Sub-Saharan Africa?

Study selection
The Preferred Reporting Items for Systematic Reviews and Meta-Analyses ("PRISMA checklist" was used in the formulation of the systematic review methodology 12 .A registration request for the review methodology has been made to the PROSPERO database. Articles were evaluated based on the inclusion and exclusion criteria from the perspective of the outcome variable (i.e., are they reporting the prevalence or epidemiology of malnutrition among children with cerebral palsy or not).

Search strategy
We searched PubMed, Google Scholar, Web Science, Cochrane databases, and other source that were conducted on malnutrition among children with cerebral palsy, and were published between January 2010 and September 2023.Since research involves constantly testing the hypotheses, staying updated with the latest publications will help us estimate the recent and updated burden of the problem.
The search was conducted using the following keywords: (Prevalence OR proportion OR Burden OR magnitude) AND (Children [MeSH Terms] OR Child OR infant OR Kids) AND (Cerebral palsy [MeSH Terms] OR Disability OR Impairment OR Special needs) AND (Sub-Saharan Africa) OR developing country OR resource-limited setting.The search terms were used separately and in combination using Boolean operators

Outcome measurement among children with cerebral palsy
There is one key outcome variable in this systematic review, which is the prevalence of malnutrition among children with cerebral palsy.The prevalence of malnutrition among children with cerebral palsy was calculated by multiplying the total number of children with cerebral palsy who had malnutrition by 100 and dividing that number by the total number of children with cerebral palsy.

Study selection and data extraction
All Studies reported the prevalence of malnutrition among children with cerebral palsy in Sub-Saharan Africa were transferred to Zotero software, and duplicate articles were removed.The pertinent information, including the names of the authors, the study's design, sample size, study area, and the number of cases/proportions of malnutrition were independently extracted by four authors (ESC, NM, FDB, and GBM).Similar to the preceding step, disagreements were discussed during a consensus meeting with other reviewers (MAM, MAS, ECA, MMG, KDT, SSC, and YSK) for the final decision on which studies to include in the meta-analysis and systematic review.

Quality assessment
We evaluated the included studies' quality using the Joanna Briggs Institute Critical Appraisal instrument for use in JBI Systematic Reviews (JBI-MAStARI) 13 .For the cross-sectional, case-control, and cohort investigations, various items were used in the scale.This systematic review and meta-analysis study included five writers (TAD, WAB, AK, AMD, and MMA) who examined the included articles.

Statistical analysis
The authors verified the accuracy of the retrieved data in a Microsoft Excel sheet before exporting it into STATA 17 for further analysis.The STATA version 17 was used for all analyses in this study.
The degree of heterogeneity was evaluated using Cochrane Q-statistics and an I 2 statistic with a p-value (< 0.05) 14,15 .The test for heterogeneity was high (75%) or moderate (50-74%) 16 .Using a random-effects model, the pooled prevalence of malnutrition among children with cerebral palsy was estimated.
Once we had determined that there was moderate or higher heterogeneity, we also looked into the cause of the heterogeneity using subgroup analysis and meta-regression 17 .Predetermined subgroups were taken into account for this, including the study sample size, study design, publication year, and study conditions.
The publication bias was estimated through a funnel plot and Egger test 18 and sensitivity analysis was piloted to examine the effect of a single study on the overall estimation.

Search result
We found 1374 studies from PubMed, Google Scholar, Web Science, Cochrane databases, and other source.There were 507 studies were excluded due to duplication.Of the remaining 867 studies, 523 studies were excluded through title and abstract screening.From a total of 344 full-text articles, 328 were excluded due to the outcome variable wasn't reported.A total of 16 studies were finally included from 09 Sub-Saharan Africa such as Nigeria, Ghana, Uganda, Kenya, Sudan, Cameroon, Tanzania, Botswana, and Zambia (Fig. 1).
The review found that the highest proportion of malnutrition among children with cerebral palsy was 90% 22 , while the lowest proportion was 37.3% 23 .The sample sizes varied significantly, with the largest study including 388 participants from Nigeria 25 , and the smallest study including only 16 participants from Zambia 31 (Table 1).

Meta-analysis
The pooled proportion of malnutrition among children with cerebral palsy in Sub-Saharan Africa by using random-effects model analysis was found to be 59.7% (95%CI; 49.8-69.6)and showed in (Fig. 2).

Estimation of malnutrition burden by sub group analysis among children with cerebral palsy
The proportion of malnutrition was also estimated by considering the sample size difference.The sample sizes were categorized as ≤ 120 and > 120, and the proportion of malnutrition was found to be 54.0 (95% CI: 44.7-63.3)and 64.5 (95% CI: 50.5-78.5)in Sub-Saharan Africa respectively (Fig. 3).Moreover, the proportion of malnutrition was estimated by accounting for the difference in the year of publication.In this regard, the study classified before ≤ 2017 and > 2017, and the proportion of malnutrition was found to be 53.7 (95% CI: 38.0-69.3)and 62.5 (95% CI: 49.7-75.3) in Sub-Saharan Africa respectively (Fig. 4).

Publication bias
Egger's regression test value showed that there is a statistically significant publication bias in this study (p < 0.044) (Table 2).Besides, a funnel plot showed an asymmetrical distribution which indicated the presence of publication bias (Fig. 5)).Moreover, the results of sensitivity analyses using the random effect model suggested were estimated (Fig. 6).

Discussion
This systematic review and meta-analysis study provides representative data on the estimation of malnutrition among children with CP in Sub-Saharan Africa.
The study suggests that an estimated pooled malnutrition burden among children with cerebral in Sub-Saharan Africa was found to be 57.4% (95% CI; 46.7-68.2).
The finding of this review, the proportion of malnutrition among children with CP is higher than the study conducted in Saudi Arabia 11 , U.S.A 7 , Argentine 10 , Bangladesh 35 , Nepal 36 , Turkey 37 , Vietnam 38 , and systematic review and meta-analysis Asia 40% 39 .
This difference might be due to the limited healthcare services, healthcare providers, infrastructure, and limited social support for the optimization of health among children with cerebral palsy by preventing, controlling, and managing malnutrition in Sub-Saharan Africa as compared to other continents 40,41 .
Moreover, food insecurity, overpopulation, low educational status, and wars can contribute to malnutrition is too high, particularly in resource-limited settings and vulnerable groups such as children with cerebral play in Sub-Saharan Africa [40][41][42][43] .
However, the proportion of malnutrition is lower than in the study conducted in Colombia 9 , and a Systematic Review and Meta-Analysis Arabic speaking countries 5 .This difference might be due to the reference standards cut-off point to diagnosis malnutrition in Colombian and Arabic-speaking countries were included mild, modern, and severe classifications, whereas this study included moderate and severe to declare malnutrition only among children with cerebral palsy 5,9 .
The finding of this review will inform the burden of malnutrition among children with cerebral palsy in Sub-Saharan Africa for the planners, policymakers, healthcare providers, government and non-governmental organizations, and researchers' up-to-date data.Additionally, this finding shows the impact of malnutrition in children with cerebral, so prevention and management through the integration of the recommendations to develop guidelines and improve the quality of service is very crucial for children with cerebral palsy in the continent.
The subgroup analysis conducted in this review aimed to estimate the proportion of malnutrition among children with cerebral palsy in various categories within the Sub-Saharan Africa region.One aspect that was examined was the difference in sample sizes, with participants categorized as ≤ 120 and > 120.The estimated proportions of malnutrition were found to be 54.0%(95% CI: 44.7-63.3)and 64.5% (95% CI: 50.5-78.5),respectively.Another factor considered was the variation in the year of publication, with studies classified as published before ≤ 2017 and > 2017.The estimated proportions of malnutrition were found to be 53.7%(95% CI: 38.0-69.3)and 62.5% (95% CI: 49.7-75.3),respectively.Taking into account the significance of a large sample

proportion malnutrition estimation among children with cerebral palsy by sample categories.
size for accuracy, it is conceivable that the proportion of malnutrition among children with cerebral palsy in Sub-Saharan Africa might be higher than the findings of this study suggest.Moreover, recent studies focusing on this population in the region have shown that, there is an increment in the prevalence of malnutrition among children with cerebral palsy.It is crucial to take these subgroup analysis findings into account to avoid misleading conclusions influenced by confounding factors 44 .

Limitations of the study
This systematic review and meta-analysis have some limitations.Firstly, the study did not assess the specific causes of malnutrition among children with cerebral palsy.Secondly, only quantitative observational studies published in English were included in the analysis, potentially excluding relevant studies in other languages.Thirdly, studies that did not differentiate between children with cerebral palsy and those with other disabilities were not considered in the analysis.

Conclusion
Malnutrition among children with cerebral in Sub-Saharan Africa was found to be very high.Hence, enhancing and developing strategic guidelines for malnutrition screening, prevention, and nutritional support are crucial among children with cerebral palsy.Furthermore, systematic review, randomized control trials, and qualitative studies are recommended to understand the burden more among children with cerebral palsy in the continent.

Figure 2 .
Figure 2. Forest plot to test of malnutrition estimation among children with cerebral palsy in Sub-Saharan Africa.

Figure 4 .
Figure 4.The proportion of among children with cerebral palsy by year publications categories.

Figure 5 .
Figure 5. Funnel plot tests for the proportion of malnutrition among children with cerebral palsy in Sub-Saharan Africa.

Figure 6 .
Figure 6.The sensitivity test for the proportion of malnutrition among children with cerebral palsy in Sub-Saharan Africa.

Table 2 .
Egger's test of the study of malnutrition among children with cerebral palsy in Sub-Saharan Africa.